275 Tips About Medical Records: A Guide for Legal Nurse Consultants

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1 275 Tips About Medical Records: A Guide for Legal Nurse Consultants Pat Iyer, MSN, RN, LNCC The Pat Iyer Group, LLC

2 The Pat Iyer Group Pat Iyer The Pat Iyer Group, LLC. 260 Route 202/31, Suite 200 Flemington, NJ Tips About Medical Records: A Guide for Legal Nurse Consultants Copyright Pat Iyer MSN RN LNCC 2013 No reproduction without written permission

3 Introduction Medical records are at the heart of litigation that involves injured people. Medical records can be maddeningly obscure, expensive and difficult to obtain, irrelevant to the issues of the case, and hard to interpret. Handwriting can be difficult to read; electronic medical records can be legible but also filled with information that is not very descriptive about the patient. Use these 275 medical record tips to better understand how the medical record is involved in litigation, formatted, and analyzed. You will learn insider information about medical records that will help you more effectively assist your attorney clients throughout litigation. This special report draws on the wisdom of legal nurse consultants and an attorney who have intimate knowledge of medical records. Invest in yourself and your skills by taking advantage of our educational resources. See us online at

4 Table of Contents Medical Records: Use in Litigation... 5 Obtaining Records... 9 Medical Records: Format Paper versus Scanned Medical Records Top Disadvantages of Manual Medical Records Know the Terms Electronic Medical Records: Advantages Electronic Medical Records: Problems Electronic Medical Records: Operational Issues Electronic Medical Records: Security, Privacy, and Confidentiality Electronic Medical Records: Medical Errors Electronic Medical Records: Quality Medical Records: Analysis Who Should Read Records Illegible Records Key Attributes of a Medical Record Personal Injury Records Physician Office Records Nursing Records: Tips for Why You Should Read the Nursing Notes Top Holes in Nursing Documentation Medical Records: Tampering Tips for Detecting Altered Records Sources Why you should invest in your education with the Pat Iyer Group

5 Medical Records: Use in Litigation The medical record serves many purposes: 1. Written documentation provides historical data that could be used for diagnosing the patient s current medical episode as well as future medical events. Medical information about previous health conditions, allergies, treatments, and outcomes is contained in the medical record. 2. Contributions to the chart are made by healthcare professionals and in turn provide authenticity of the data. Laboratory and radiology results, outpatient and inpatient procedures, and notes from specialists consulted on the patient s behalf become a permanent record. 3. Review of the written records affords the hospital a means to assess a physician s abilities and competency. Outcomes achieved through the physician s care and treatment of a patient can be evaluated. Chart surveys and reviews are usually conducted as a means to capture data on adverse outcomes. Patterns of adverse reactions and negative outcomes for patients, validated through statistical analysis, are presented to the appropriate physician with recommendations for improvement. 4. Documentation of diagnostic testing and procedures can be collected for statistical data. The organization can determine how often procedures or diagnostic tests are ordered. These data can be used to justify changes to a department s hours of operation, adjusting number of personnel, or a department relocation or remodeling to accommodate the volume

6 5. Facilities also are subject to health department, Joint Commission and other healthcare organizations that conduct audits of the hospital. Data obtained from patients medical records are used to evaluate whether the facility receives the license, accreditation, or certification associated with the surveying entity. Evaluation of whether or not the healthcare organization has complied with the accepted standards of care associated with the surveying entity is made during the survey. It is critical for the healthcare organization to meet these standards in order to achieve and maintain a reputation for high quality patient care, to attract competent medical staff, and to compete in the healthcare market place. 6. Physicians and healthcare providers can review previous health records to obtain accurate patient data regarding any surgery, injury, medical conditions, medications ordered, diagnostic testing, therapies provided, dates of treatment, and the patient s tolerance or reaction to any of the above medical encounters. This provides an opportunity for the physician to avoid repeating unnecessary diagnostic testing, expedites patient care by avoiding unnecessary delays in treatment, and promotes safer patient care by avoiding therapies and medications that previously resulted in negative patient reactions or are medically contraindicated. 7. Providing statistical analysis to physicians and healthcare professionals is another value derived through the use of the written medical record. With proper authority, they may analyze records specific to their specialty area, determine volume of patients treated within a certain period of time, and calculate how many procedures and consultations they have performed. 8. The record is also of value when used to support and defend against legal actions. The patient record, as the legal documentation of treatment provided by and recommendations made by healthcare professionals, is the only recognized means accepted by the legal system for protecting the healthcare professionals legal interests. 9. A patient s medical record may form the basis for medical research and teaching. The legal status of the record certifies it as an authentic data source. This authenticity renders the data useful and accurate for researchers and other healthcare professionals in their efforts to develop new theories, treatments, and processes. 10. Public health and homeland security initiatives are indicative of today s ever changing and fast-paced world. Specific areas included in this area address the process of observing and reporting symptoms of disease or potential threats to the health of large segments of the population. Data obtained from medical records also may be sought to detect any threat of bioterrorism. 11. Various state and federal laws require that certain events, such as births and deaths, as well as certain diseases, be reported to public health agencies. Written

7 medical record information facilitates compliance with these types of laws and regulations. 12. Patient self-management is a reflection of today s patient. A growing number of patients have taken the initiative to assume more responsibility for their individual health efforts. A by-product of this initiative includes understanding and actively participating in their healthcare. Patients themselves are now becoming one of the main users of their healthcare information. 13. Most healthcare organizations are in a competitive market and seek to highlight their organizations services. In an effort to justify existing programs and services or to plan for future outreach initiatives, these organizations are utilizing medical record data. Post-discharge data analysis is important in identifying successful and financially feasible services. It can also create an awareness of potentially unsuccessful endeavors. 14. The record is reviewed for documentation of billed treatments being completed on the patient s behalf. As more claims are now being billed to Medicare and third party payors, it is imperative that no fraudulent billing occurs. In an effort to comply with legitimate billing practices, specific processes have been implemented and trained staff hired by healthcare organizations and healthcare providers to review patient records and validate claims prior to submitting them for reimbursement. Fraud investigators working for insurance providers or any federal or state operated programs complete detailed reviews of the medical record in an effort to detect cases of billing fraud and abuse prior to processing the claims for distributing insurance benefits. 15. Data obtained from medical records support research efforts in several ways, e.g., to complete clinical research, create new products and drug therapies, and evaluate the value of technology in healthcare. The medical record is reviewed to determine whether or not outcomes of patient care achieved are appropriate. It is also evaluated to calculate whether the care provided was not effective or provided in the most economical manner. Healthcare information can detect potential risk factors for certain populations, form the basis for creating patient registries and databases for future contact and patient care encounters, and determine the financial feasibility of record systems

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9 Obtaining Records 16. When you recommend to your clients that they obtain medical records, consider the investment of resources needed to obtain medical records. Be aware of the investment in time, money, and space. HIPAA-compliant authorizations must be executed, requests sent (and often re-sent), and fees paid. Some healthcare providers are notoriously slow in responding to requests, which requires the law firm to expend additional resources to follow up. 17. Recognize that it is inefficient to request records until the potential value of the claim has been assessed. The point at which a plaintiff s attorney should request medical records depends greatly on the experience and medical knowledge of the reviewer. The great majority of claims can be determined to be without merit, present insurmountable difficulties in proving causation, or suggest damages insufficient to justify litigation, all based on historical information provided by the potential client with no, or minimal, documentation at hand. 18. Keep these scenarios in mind when making a recommendation about requesting medical records. a. The allegations, if supported by records, would present an actionable claim, and the potential scope of damages. b. The initial evaluation presents facts so clear that the attorney will feel confident that the case is likely to go forward. c. The information at hand sounds promising, but specific records are needed to determine the extent to which deviation or causation can be proven. d. The case appears to be a long shot, where it seems unlikely that the necessary elements will be proven, but the injury is so serious (and, proportionately, the damages so large) as to justify the investment in requesting and reviewing the records. 19. Be aware of the factors that should be considered by a plaintiff s attorney when deciding which records to request while evaluating a potential medical malpractice claim. They include the likelihood that the attorney will pursue the case, the volume (and potential cost) of the records and the available resources (whether those of the attorney or the client) to pay the cost, and the nature of the

10 information that will be required to establish the viability of the case. 20. The facts of each case will determine whether full certified copies of all records are needed, or whether abstracts may be sufficient. Full certified copies of medical records relating to where the alleged medical malpractice occurred are needed to complete an evaluation of the merits of a claim. 21. Be aware of any state-specific laws that regulate what the provider may charge to supply a copy of the chart. 22. When a specific deviation or a particular type of deviation is alleged or suspected, be familiar with the materials that will be required to thoroughly assess the claim. If a failure to screen for colon cancer is alleged, for instance, the chart of the primary care physician may be sufficient to reveal the deviation and if it contains reports from the surgeon and oncologist to assess causation and injury as well. 23. In cases of delayed diagnosis of breast cancer or negligence in interpretation of prenatal ultrasound studies, it is likely that original images of the diagnostic study in question (such as mammography, breast ultrasound or fetal ultrasound) will be required. When in doubt, consult with the expert who will ultimately be asked to certify or otherwise assess the validity of the claim or the expected testifying expert or experts. 24. If there is a short statute of limitations, the plaintiff attorney may need a more comprehensive set of records rather than requesting them piecemeal, except when the expected testifying expert is very clear about what would be necessary to provide a definitive opinion as to deviation and causation. 25. A liability expert will have limited need to review voluminous medical records for care rendered after the care alleged to be negligent. A discharge summary may suffice. 26. A host of records may be relevant in a specific case. Depending on the circumstances of the claim the LNC should examine records from the hospital, emergency room, or emergency center where the injury was initially treated, emergency medical services (ambulance or medical intensive care unit/micu), hospital that relate to treatment and surgery, physicians and specialists who examined or treated the plaintiff before and after the incident, outpatient imaging (x-rays, MRI scans, CT scans, and so forth), any outpatient labs where blood work or other tests (EMG, EKG, and so forth) were done, inpatient and outpatient rehabilitation including physical therapy, occupational therapy, and so forth,

11 outpatient pain treatment centers, the actual radiographs and reports that relate to the injury, the actual pathology specimens and reports that relate to the injury, billing, visiting nurse home care agencies, mental health providers, substance abuse treatment and HIV testing, autopsy, and nursing homes

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13 Medical Records: Format Paper versus Scanned Medical Records 27. Medical records scanned and saved on a hard drive or disk require very little storage space (until they are printed), are easily reproduced by copying the disk, and may provide individual files that can be sent by or transported using a USB drive. 28. The decision of whether to request records in digital format, such as scanned records, is based in part on the degree of sophistication of the records. Typically, medical records are simply optically scanned and stored in a portable document format (PDF) image file. 29. Scanning medical records and saving as a PDF may save space but it may not save money if the records have to be examined by consultants and experts. 30. The PDF format makes it difficult for the reviewer to search for handwritten text, forcing the reviewer (attorney, legal nurse consultant, expert witness) to page through each screen to find the desired parts of the chart. 31. If the file is large, and the pages are not numbered and indexed, it can be cumbersome to work with and review. 32. Some reviewers find it easier to print out and work with a paper copy, which allows flagging and annotation; this results in a standard paper record. This is particularly true when records are voluminous. 33. The digital format is extremely convenient for review if the scanned records are indexed, allowing the reviewer to jump from section to section (e.g., progress notes to laboratory results, medication records to operative reports)

14 34. Scanning a batch of unorganized records is often a waste of time. Remember, it is more economical to present the reviewer, whether that person is an expert, a consultant, or an attorney, with information that is organized in a logical way. 35. Consider the ease with which the expert will be able to locate information in a scanned record. How will this affect the expert s performance in a deposition or trial when the opposing counsel asks the expert to refer to a particular page? Paper records may be the only practical solution of the majority of experts

15 Top Disadvantages of Manual Medical Records 36. The patient s healthcare record has evolved into the most reliable source of data available to fulfill multiple purposes and functions. As many as 150 end users seek access to a standard medical record. With ever increasing numbers of individuals needing the information in a medical record, the physical condition and location of the record becomes extremely important. 37. There are several types of costs associated with manual patient records. One type, duplication of the record, requires paper and copying supplies, as well as the staff to create and distribute the copies. It is costly to hire medical personnel within a healthcare facility to assemble, file, retrieve, or distribute the paper chart. 38. Storage of the paper record necessitates the use of valuable space that could be better utilized. The records also need to be protected from water, fire, or mishandling of the paper to preserve their physical integrity. 39. One of the most expensive disadvantages of the paper record is duplicate patient testing required to replace lost or missing test results. Repeating procedures may jeopardize the patient s health, creating a potential opportunity for an adverse medical event. Duplicate testing wastes scarce medical resources (time, staff, supplies, and equipment) that could be used for other patients. It is a contributing source to the rising costs of health care by generating additional charges to be billed to the patient, insurance company, or other third- party payor. 40. A related issue pertains to ordering procedures or tests that are either unnecessary or contraindicated. These types of decisions, when based on inadequate information or delayed results, create a potentially harmful situation

16 for the patient and a needless expense for all concerned. Claims submitted for medical errors that could have been prevented with accurate and accessible patient information are issues that are seen with the use of a paper record. 41. Lost productivity results from various inadequacies of the paper record. This affects multiple departments in a healthcare facility. Searches for misfiled charts waste time. Staff members time is required to deliver paper records to a specific location. If the paper record is not readily available, clerical staff responsible for filing documentation may need to make several attempts before the task is completed. 42. Medical errors may be made if the staff makes decisions on inadequate information. 43. There is no ability to sort data fields in a paper record. Staff responsible for reporting mandated data elements to the appropriate organizations must perform a manual review. This is a very labor-intensive process, and inaccuracies can occur. 44. Of great concern is the lack of access to the paper record. Only one person at a time may use the chart and the chart has to be in a single location. Healthcare staff needing access to the record must wait until it is available for their use. This also contributes to the difficulty of updating the paper record, especially for an active patient s chart since that chart travels with the patient to each location of care. 45. Delivering documentation by hand to the patient s temporary location lends itself to the potential for losing or misplacing the records. 46. Delayed access to the chart negatively affects coding, billing, and reimbursement processes. 47. The issue of quality encompasses the physical record, the documentation, and patient care. There are limitations to the physical quality of the paper record. Paper is fragile and does not last permanently. Normal use of the record may result in torn or stained documents. Also, over the years, ink used to complete documentation can fade. 48. Actual damage resulting from water or fire is another threat to the physical integrity of the paper record. 49. Quality of the actual documentation varies based on the healthcare provider s documentation skills and knowledge level. While standardization of the data documentation has improved over the years, not all providers use the same abbreviations, terminology, format, or chart organization. This can result in incomplete or inaccurate healthcare data collection. 50. Handwritten information may be illegible, creating the potential for errors in patient treatment or medication orders

17 51. Fragmentation of the patient s record occurs as the result of multiple encounters with different healthcare providers. Due to disparate patient documentation and billing systems, there is often minimal or no exchange of information that contributes to compiling a longitudinal medical history for the patient. Each provider or facility has a limited portion of the patient s overall health information. Some minor communication may be provided between referring and consulting physicians, but only for a specific encounter. 52. The level of fragmentation varies based on several factors. These factors include: the patient s ability to communicate pertinent health information to the provider; the ability of the provider to collect information that is accessible to other providers; the provider s ability to directly elicit health information from the patient and any written documentation to create an appropriate treatment plan; and the limitations of the patient record system(s) that are being utilized to collect and disseminate information. 53. A well planned and implemented electronic medical record (EMR) system should address and/or alleviate many of the general disadvantages of the paper record. This is an immense undertaking that requires an in-depth review of current processes, a detailed strategy for determining the organization s future needs and goals, an organization s willingness and ability to make significant changes, and the financial investment to achieve the desired results. It is also a very timeintensive project that demands the utmost dedication and commitment by the entire health system. Patients, providers, and other interested parties could all expect to derive benefits from a properly planned and installed automated system

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19 Know the Terms 54. Metadata is data about data. It indicates how and when a computer or application was used and by which person. The query audit trail or medical record review inquiry details who looked at the medical record, when and for how long and whether the hard copy of the medical record left the medical records department. The audit trail includes the additions, deletions, and edits for the time frame at issue. It identifies which people documented when. 55. The data dictionary is an explanation of the terms that facility uses in association with the medical record. The nursing data dictionary may allow documentation of a number, such as 70 to be shorthand for breathing normal. Or the facility may use the word breathing to provide multiple descriptions such as clear, labored, or even. 56. Obtaining a complete copy of an electronic medical record has proved to be a significant challenge. Unlike paper records, which are usually organized in a specific fashion, electronic records often make little sense when simply printed out. The attorney should ask for all of the data, including older, paper records kept in storage. You want all of the relevant data in all core data sources, not just the ones that are easiest to print. 57. The PHI (Protected Health Information) disclosure log is a HIPAA-mandated list of what, where, where, and by and to whom the patient s medical record has been disseminated. It will tell you where you can find other copies of your client s medical records for comparison

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21 Electronic Medical Records: Advantages 58. Combining the costs of care, reduced income, decreased household productivity and disability associated with treating medical errors can total between $17 and $29 billion dollars annually. Other losses include decreased confidence in America s healthcare system, loss of satisfaction with health care by patients and providers, physical discomfort and increased hospital stays for patients suffering from the medical error. Lower morale for healthcare providers, lower school attendance rates, and decreased health status of the population are additional losses attributed to medical errors. 59. Medication errors are the most prevalent type of preventable mistake. Approximately 1.5 million people suffer adverse reactions each year, resulting in at least $3.5 billion being spent to care for the patients suffering from these errors. Each hospital patient suffered at least one medication error per day during an inpatient stay. 60. Drug-related errors in hospitals that could have been prevented are numbered at 400,000 per year. These are the errors that generated $3.5 billion in unnecessary healthcare costs. Preventable medication errors for patients in longterm care settings were calculated to occur at a rate of 800,000 with an associated cost of $887 million dollars. The number of occurrences for Medicare only patients in outpatient clinics was listed at 530,000. As high as these costs are, lost productivity and lost wages are not included. 61. Hand-written prescriptions are related to the high volume of errors due to illegible hand writing and incorrect dosage information. The use of computer technology to prescribe medications, in combination with other software applications, is viewed as a potential means for decreasing the high volume of medication errors. 62. Potential savings to healthcare organizations implementing an EMR have been calculated. Billions could be saved each year if healthcare information was

22 electronically shared between providers and healthcare organization using a standard format. 63. A benefit associated with implementation of an EMR relates to the facility s standing in the area it serves. Improved quality of patient care resulting from electronic healthcare records can increase name recognition and branding in its geographical market. This branding increases the likelihood that patients will choose the facility for providing healthcare. It also serves as a marketing tool for recruiting physicians and developing physician referral patterns. 64. Coordination of care is significantly improved and information is available to providers regardless of their physical location or time of day. Electronic documentation provides real time entry of patient health information and promotes accuracy of the data. It increases efficiency of the referral process and the patient information available to the consulting physician is more comprehensive. Combined use of any of these features facilitates improved quality of patient care, promotes patient safety, and ultimately reduces morbidity and mortality rates. 65. Cost savings can be achieved when the documentation system is integrated with the billing system. This is accomplished in several ways. Charge capture is improved, so missed revenue is reduced. Reimbursement of billed services, as a result of more accurate documentation, is increased. Elimination of laborintensive entry of billing information reduces staffing costs and potential for human errors. Evidence also suggests that the physician will see an increase in revenue due to improved workflow associated with a computerized patient record. Improved workflow allows the volume of patient appointments to be increased with proportionately minimal effect on current staffing levels. 66. There is 20-50% waste in any healthcare system. EMRs help to remove some of that waste. 67. Pen and paper medical records are plagued by illegible handwriting along with non-standardized and dangerous abbreviations, which can lead to medical errors. Electronic records are legible and are programmed to use only approved terminology and abbreviations. 68. Electronic medical records may be supplemented with resources, such as information about medications, which is useful when prescribing drugs. Systems that include data from laboratory systems can incorporate clinical prompts, for example, which may warn against prescribing a specific medication in the presence of declining kidney or liver function. 69. Use of bar coding technology reduces medication errors. 70. Access to a medical record may be electronically limited. For example, a nursing assistant may be permitted to only enter vital signs but not review orders,

23 laboratory results, or write nursing notes. A paper medical record may be viewed by anyone. 71. Each entry in the electronic medical record carries a time and date stamp, as well as the identity of the user. This makes it easier to reconstruct events after a patient injury occurs. 72. With sufficient safeguards in place, an electronic record is more reliable and less likely to be lost. 73. Health care is an information business. Without having all the information available to everyone who needs it at the point of care, care cannot be either costeffective or high quality. The hospital can control use of resources. They can modify order sets to take the more expensive treatment out of the entry set, or force physicians to sign off on the order. 74. The enormous amount of data that are collected about a person s health can be stored and organized in a more efficient method than our current paper system permits. 75. Tampering with the medical record is much more difficult to do with an electronic system. Software typically permits the healthcare professional to correct errors in typing and phrasing immediately after the error is made. Software programs contain a feature that makes the entry unalterable after a certain time or event. 76. One of the most obvious benefits is the creation of legible records. Computer printed records are completely legible, therefore eliminating the confusion caused by guessing at the meaning of handwritten words. 77. The identities of the healthcare providers are easy to determine, as each entry is followed by either initials or a full name and status MD, RN, LPN and so on). If the entry is followed by initials, somewhere else in the document the person s full name will appear. 78. The programs which incorporate the facility s standards of care prompt the healthcare provider to enter the essential information. For example, an admission assessment would include information that would identify the patient s risk for skin breakdown or for a fall. This type of prompting focuses the nurse s attention on key clinical issues and reminds the nurse to collect and enter the data that would fulfill the standard of care. 79. The enormous amount of data that are collected about a person s health can be stored and organized in a more efficient method than our current paper system permits. It is time consuming to find data in a patient s paper chart. The larger the chart becomes, the less easy it is to use it to locate key information. An electronic medical record can be searched to find key pieces of information. The

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